Aquifer High Value Care 03: 65-year-old woman – Adult preventive care and value Case Study

High Value Care 03: 65-year-old woman – Adult preventive care and value
Author(s): Heather Harrell, MD University of Florida College of Medicine
PREVENTIVE CARE REVIEW
TEACHING
You are rotating in the outpatient clinic with Dr. Pritti, who asks you to see Lynda Jacobsen, a 65-year-old homemaker here for her “Welcome to Medicare” wellness visit. She reports no acute concerns but wants to get “every test Medicare will cover” as she plans to live to be 100. You recall there is more to prevention than just ordering tests.
Question
Which of the following are major categories of preventive care? Select all that apply.

Stages of change
Screening examinations
Diagnostic testing
Behavioral counseling
Immunizations
Prescription medications
Integrative care plans

SUBMIT
CONTINUE
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Answer Comment
The correct answers are B, D, E.
The four major categories of preventive care are:

Screening (B),
Behavioral counseling (D),
Immunizations (E), and
Chemoprevention.

“Stages of change” (A) is a model used to help assess an individual’s readiness to make a behavioral change and can be helpful when performing behavioral counseling.
Tests used for screening are often the same as those used for diagnosis. However, the purpose of screening tests is not just to identify potential disease but to identify diseases in time to prevent consequences and complications. Diagnostic testing (C) is performed to determine the cause of a symptom and prescription medications (F) are used to manage health problems.
An “integrative care plan” (G) could mean applying integrative medicine (a blend of allopathic medicine and complementary medicine) into a preventive medicine plan, but this term is also used in many other contexts and is not a major category of preventive care.
HISTORY
HISTORY
You interview Ms. Jacobsen and learn that she enjoys good health. She is transferring her care from her gynecologist, Dr. Archy, because her friends said that at her age she needs an internist. She had seen Dr. Archy for the past 15 years, ever since she underwent a hysterectomy for uterine fibroids (leiomyomas, or benign tumors of the uterine muscle).
You review Dr. Archy’s records:
Test Results

Pap smears annually: All normal
Breast examinations annually: All normal
Mammograms annually: All normal
Colonoscopy 5 years ago: Normal
Bone densitometry every 2 years: Normal
Fasting lipid profile annually: Most recent LDL 98 mg/dL; HDL 50 mg/dL; triglycerides 78 mg/dL

Immunizations

Annual flu vaccine
Herpes zoster vaccine (Zostavax) 1 year ago

Ms. Jacobsen follows a low-fat diet and takes a daily multivitamin. She attends Zumba classes three times a week and sees a personal trainer weekly for weight training. She does not use tobacco products and drinks 2 to 3 alcoholic beverages a night with her dinner.
The physical examination is normal, including a BP of 120/70 mmHg and BMI of 24.9.
As you leave the room to speak with Dr. Pritti, Ms. Jacobsen hands you a flier she picked up at her church advertising “Vital Life,” a mobile screening bus that offers the following tests:

Comprehensive metabolic testing

Fasting lipid panel

Advanced cardiac screen (C reactive protein, lipoprotein a, homocysteine)

ECG

Vascular disease screen (ankle-brachial index, ultrasound of abdominal aorta and carotid arteries)

EBCT scan of the chest for coronary artery disease

Bone densitometry

She asks you to give the flier to Dr. Pritti and let her know she wants every test that Medicare will cover. You would like to see if the tests she is interested in are recommended for someone of her age and with her medical conditions.
Question
Which of the following are reliable sources for high quality, evidence-based preventive care recommendations? Select all that apply.

U.S. Preventive Services Task Force (USPSTF)
Centers for Disease Control and Prevention (CDC)
Agency for Healthcare Research and Quality (AHRQ)
Choosing Wisely® Campaign
“Prevention” website

Answer Comment
The correct answers are A, B, C, D.
Preventive Care Guidelines
There are numerous guidelines that pertain to preventive care, and it can be difficult to decide which are reliable. Health and Medicine Division (formerly The Institute of Medicine (IOM) has proposed the following eight standards that should be part of guideline development:
Standard 1: Establishing Transparency
Standard 2: Management of Conflict of Interest
Standard 3: Guideline development group composition
Standard 4: Clinical practice guideline-systematic review intersection
Standard 5: Establishing evidence foundations for and rating strength of recommendations
Standard 6: Articulation of recommendations
Standard 7: External review
Standard 8: Updating
The USPSTF (A) is considered by many to be the gold standard in this country for evidence-based preventive care recommendations. It is the reference used by Medicare to determine which screening tests will be covered.
The USPSTF used to make immunization recommendations but now defers to the CDC (B) guidelines because the CDC has its own rigorous review process.
AHRQ (C) relies primarily on the USPSTF recommendations.
Choosing Wisely® (D) is an initiative of the American Board of Internal Medicine Foundation that has been joined by over 50 specialty societies. Unlike the USPSTF, which focuses more on what preventive care physicians should recommend, Choosing Wisely® is a compilation of evidence-based lists of tests (both preventive and diagnostic) and treatments that physicians and patients should question because they are of low value.
While some commercial internet websites, such as “Prevention” or other media (E) base their recommendations on guidelines that follow the standards described above, this is not always the case. These types of websites contain obvious conflicts of interest with advertisers and sponsors. Additionally, anecdotes and low quality studies are weighted similarly to high quality evidence, the process by which recommendations are made is unclear, and there is no clear peer review process.
 
 
 
 
PREVENTIVE SERVICES GUIDELINES
TEACHING
You know Dr. Pritti will ask for your thoughts, so you decide to use the electronic preventive services selector (ePSS) app that you downloaded from the AHRQ website. The app will show you all of the USPSTF preventive service recommendations for a sexually active, nonsmoking woman 65 years of age listed by grade.
The USPSTF grades their recommendations based on the amount and quality of evidence supporting each intervention.
USPSTF Grade Definitions after July 2012
View full table provided by US Preventive Services Task Force

Grade
Definition

A
The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

B
The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C
The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgement and patient preferences. There is at least moderate certainty that the net benefit is small.

D
The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

I Statement
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Question
Match each test listed on the Vital Life brochure with its USPSTF grade. (For each item, select an option from the list box.)
Bone densitometry  — select an option — Grade B Grade C Grade D Grade I
Fasting lipid panel  — select an option — Grade B Grade C Grade D Grade I
Abdominal aorta ultrasound  — select an option — Grade B Grade C Grade D Grade I
Carotid artery ultrasound  — select an option — Grade B Grade C Grade D Grade I
ECG  — select an option — Grade B Grade C Grade D Grade I
Advanced cardiac screen (C reactive protein, lipoprotein-a, homocysteine)  — select an option — Grade B Grade C Grade D Grade I
Ankle-brachial index  — select an option — Grade B Grade C Grade D Grade I
EBCT (Electronic Beam Computed Tomography) scan of the chest for coronary artery disease  — select an option — Grade B Grade C Grade D Grade I
SUBMIT
CONTINUE
 
 
Question
Match each test listed on the Vital Life brochure with its USPSTF grade. (For each item, select an option from the list box.)
PARTIALLY CORRECT
Bone densitometry  — select an option — Grade B Grade C Grade D Grade I Grade B
Fasting lipid panel  — select an option — Grade B Grade C Grade D Grade I Grade C
Abdominal aorta ultrasound  — select an option — Grade B Grade C Grade D Grade I Grade D
Carotid artery ultrasound  — select an option — Grade B Grade C Grade D Grade I Grade D
ECG  — select an option — Grade B Grade C Grade D Grade I Grade D
Advanced cardiac screen (C reactive protein, lipoprotein-a, homocysteine)  — select an option — Grade B Grade C Grade D Grade I Grade I
Ankle-brachial index  — select an option — Grade B Grade C Grade D Grade I Grade I
EBCT (Electronic Beam Computed Tomography) scan of the chest for coronary artery disease  — select an option — Grade B Grade C Grade D Grade I Grade I
SUBMIT
Answer Comment
Correct answers:
Grade A

Blood Pressure screening

Grade B

Bone densitometry

Grade C

Fasting lipid panel

Grade D

Abdominal aorta ultrasound
Carotid artery doppler
ECG

Grade I

Advanced cardiac screen
Ankle-brachial index
EBCT

The USPSTF recommends screening for high blood pressure in adults aged 18 years or older. The USPSTF recommends obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment.

Use the National Heart, Lung, and Blood Institute’s (NHBLI’s) 10-year cardiac risk calculatorto calculate Ms. Jacobsen’s cardiac risk. Even though her lipid levels fall just within normal limits (total cholesterol 199 mg/dL and HDL 41 mg/dL), Ms. Jacobsen’s cardiac risk is low, so screening her would fall into the USPSTF’s Grade C category.

(Note that the latest AHA/ACC guidelines recommended checking lipids to calculate 10 year ASCVD risk every four – six years in healthy adults aged 40 – 75.)
Similarly, the USPSTF recommends (Grade B) bone densitometry in women 65 or younger if they are at increased risk of fracture (i.e., have a 10-year fracture risk of ≥ 9.3%, or that of a 65-year-old white woman).

If Ms. Jacobsen’s bone density was unknown, her risk of fracture calculated by FRAX(a fracture risk assessment tool developed by the World Health Organization) would be 12% for any fracture and 2.3% for a hip fracture.
Jacobsen, however, has previously been screened and was determined to have normal bone density. When her known normal femoral neck bone density is included in the FRAX calculation, her 10-year risk of fracture is reduced to 6.5% (any fracture) and 0.1% (hip fracture). So, the B recommendation does not apply to Ms. Jacobsen.

Obtaining screening ultrasounds (for abdominal aorta aneurysm in women and carotid artery stenosis) and performing ECGs in low-risk adults both receive Grade D recommendations from the USPSTF. This means there is evidence that routine testing may result in greater harm than benefit to the patient. The recommendation is therefore against ordering these tests for screening purposes. Aquifer High Value Care 04: 80-year-old woman – Medications and value
There is insufficient evidence (Grade I) about using nontraditional coronary artery disease risk factors, including electronic beam computed tomography (EBCT) results, C reactive protein, lipoprotein-a, homocysteine, and ankle-brachial indices to make recommendations for or against these interventions.
 
 
TESTING RISKS AND BENEFITS
TEACHING
Dr. Pritti asks you, “What do you think of this brochure? Would you recommend we order any of these things?”
You answer, “I looked at the USPSTF guidelines, and it seems like she isn’t due for any of the tests she is requesting, though it does look like she needs a pneumonia vaccine and the TdaP booster, as she hasn’t had those.
“She is expecting to get her blood drawn, and I’m afraid she will be upset if we don’t do it. I don’t think it will really harm her to get a little blood work if it keeps her from getting upset. However, we can tell her we checked her blood pressure as recommended on the brochure and that it looks normal.”
Dr. Pritti responds, “I agree with your vaccine recommendations, and I also agree that it is important to incorporate a patient’s goals into our decision-making. However, I’m not sure I agree that there is no potential harm to testing without a clear indication.”
Question
What are potential harms of minimally invasive tests like blood work or an EKG? Select all that apply.

Falsely abnormal tests
Incidental findings
Financial cost to the patient
Financial cost to society
Anemia
Time spent reviewing tests that could be spent in other ways of more direct benefit to patients
Patient anxiety

Answer Comment
The correct answers are A, B, C, D, F, G.
All tests have the possibility of yielding a falsely abnormal result (A) or incidental finding (B), either of which can lead to further testing and patient anxiety (G). For example, a third to half of patients with angiographically normal coronary arteries have Q or ST wave abnormalities, or T wave inversions on a resting ECG.
Likewise, most tests impose a financial cost to the patient (C) (see High Value Care 06: 65-year-old man – Paying for value: Insurance Part 1 for more information).
A screening test is performed in a patient who, by definition, has no symptoms. Thus, if the result yields no clear benefit to the patient, then the testing is completely unnecessary. This is in contrast to a patient with symptoms, who requires evaluation: even though there is a cost and the potential for false positive results, the testing is necessary, and there is potential for the patient to benefit from it. Aquifer High Value Care 04: 80-year-old woman – Medications and value
While not all tests have a financial cost to society (D) – indeed, it is financially beneficial to screen for some diseases – tests without a clear benefit to the patient are also costly for society (see the Expert button for more about population health).
Reviewing the results of tests requires time (F) and, given current time constraints in ambulatory medicine, time spent reviewing results of unnecessary testing is wasted time that is of no value to patients or the healthcare system.
Anemia (E) is a potential consequence of repeated blood draws, such as can occur during a hospitalization, but a single blood draw for outpatient tests will not cause anemia.
 
 
 
TESTING COSTS
THERAPEUTICS
You tell Dr. Pritti, “That went better than I thought it would. I noticed you didn’t repeat my physical examination. Should I not have done all of that?”
Dr. Pritti answers, “Technically, the only parts of the physical examination that her ‘Welcome to Medicare’ visit requires blood pressure, BMI, and vision screen, which I reviewed and did not need to repeat. The rationale is that it is unlikely we will pick up any significant abnormal findings in a healthy, asymptomatic patient. Thus, our time would be better spent assessing risk and counseling. There are many good reasons to perform a physical examination, but based on your insights about her expectations and concerns about her alcohol use, I wanted to make sure we had time to address those issues. As it turned out we did need that time today.”
More of Ms. Jacobsen’s records arrive on the fax and you discover that her yearly “routine blood work” consisted of a CBC with differential, lipid panel, comprehensive metabolic panel, and thyroid stimulating hormone. You confirm that her bone densities, pap smears, and mammograms were all normal. Aquifer High Value Care 04: 80-year-old woman – Medications and value.
Now that you have reviewed a few of the preventive care guidelines, you identify many potential areas of waste in Ms. Jacobsen’s past care. You wonder what was the financial cost of past testing that was not of clear benefit to her and decide to make a comparison:
Cost of Testing Over 15 Years
Cost of Testing
You ask Dr. Pritti, “I guess I knew that all tests have a potential downside, but I was also concerned about her alcohol consumption, and I wondered whether you ever would compromise on something a patient wants in order to put them in a better mood when you need to discuss something they need to change like alcohol or diet?”
Dr. Pritti responds, “That’s a good question, and I don’t want to give you the impression that shared decision making can’t accommodate reasonable compromises. Why don’t we go into the room together and I will try to role-model the process for you.”
 
Question
Which of the five major steps to behavior change were applied?

Assess
Advise
Agree
Assist
Arrange
Assurance

SUBMIT
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TEACHING
CARE DISCUSSION WITH PATIENT
CARE DISCUSSION
You reflect on the interaction you just observed.
Question
Which of the five major steps to behavior change were applied?
The best options are indicated below. Your selections are indicated by the shaded boxes.

Assess
Advise
Agree
Assist
Arrange
Assurance

SUBMIT
Answer Comment
The correct answers are A, B, C, D, E.
The “5 As”
The five major steps to intervention-also known as the “5 As”-are:

Assess
Advise
Agree
Assist
Arrange

You assessed (A) Ms. Jacobsen’s alcohol use, which allowed you to identify a problem Aquifer High Value Care 04: 80-year-old woman – Medications and value.
Dr. Pritti advised (B) her to cut down her alcohol using clear, personalized language.
Ms. Jacobsen agreed (C) and, with you and Dr. Pritti, collaboratively set specific goals.
Dr. Pritti arranged (E) follow up by telephone in a week.
Although assist (D) is one of the 5 As, it was not clear that Ms. Jacobsen required further assistance.
Assurance (F) is not one of the five major steps to intervention.
Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care
Aquifer High Value Care 04: 80-year-old woman – Medications and value

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